经自然腔道内镜手术的基础研究现状与进展

经自然腔道内镜手术(natural orifice transluminal endoscopic surgery,NOTES)是国内外研究的热点,目前已从动物实验进入初步临床应用阶段。在这数年的研究与临床实践中,NOTES所面临的问题越来越清晰,其与常规开腹及经典腹腔镜手术的对比也已有了初步结论,现对其进行总结回顾。     

微创手术新概念—经自然腔道内镜手术的现状与发展

微创外科成为21世纪发展的重要趋势,层出不穷的微创治疗手段昭示着一个微创外科时代的到来,随着腹腔镜技术和理念的普及、内镜治疗器械和技术的进步等,腹壁无瘢痕手术(scarless surgery)成为人们追求的新的目标,现将经自然腔道内镜手术的现状与发展作一综述。     

经胃及阴道内镜胆囊切除动物实验研究

目的:探讨经胃和阴道行内镜胆囊切除术的安全性、可行性、优缺点以及安全关闭自然腔道切口和预防术后腹腔感染的方法。方法:采用雌性猪5只。3只经胃手术,术前分别用1 000、2 000和3 000ml生理盐水洗胃;2只经阴道手术,术前分别用碘伏和抗生素冲洗阴道。经脐置入气腹针,建立气腹后置入2个5mm Trocar,腹腔镜及操作器械经此入腹。经口(阴道)置入内镜后打开胃前壁(阴道后穹隆),进入腹腔。在内镜监视下行胆囊切除术,切下胆囊随内镜经口(阴道)取出,胃(阴道)壁切口腹腔镜下间断缝合关闭。生理盐水和抗生素冲洗腹腔,结束手术。结果:5例手术均获成功,自然腔道切口安全关闭,无出血及周围脏器损伤等并发症发生。术前用1 000及2 000ml生理盐水洗胃后胃液标本、用抗生素处理阴道后阴道分泌物标本细菌培养呈阳性;3 000ml生理盐水洗胃标本及碘伏清洗阴道后标本细菌培养阴性;术后腹腔冲洗液细菌培养显示4只动物术后腹腔内无细菌生长,1只细菌培养阳性,菌量为430cfu/ml。结论:经胃及阴道内镜胆囊切除术是安全可行的。目前内镜还不能完全满足NOTES的要求,联合腹腔镜可降低NOTES操作难度,提高安全性。生理盐水洗胃、抗生素或碘伏消毒阴道及生理盐水、抗生素冲洗腹腔可降低自然腔道和术后腹腔菌落数,有助于降低术后腹腔感染的发生率。     

循自然腔道内镜手术临床应用现状

循自然腔道内镜手术（natural orifice transluminal endoscopic surgery,NOTES）的概念由Kalloo等于2004年正式提出。NOTES是以内镜为治疗工具,经自然腔道（食管、胃、阴道、膀胱、结直肠等）而非皮肤切口．对腹腔脏器疾病进行治疗的微创外科治疗方法,其作为新型腹壁无瘢痕手术比腹腔镜手术更为微创。NOTES从概念的提出到动物实验及临床应用,发展迅速。     

经脐单孔腹腔镜外科技术的现状与展望

创伤越来越小是当今外科的发展方向,外科手术已经经历了从传统的开腹手术到微创的腹腔镜手术的过渡,如今又正从多孔腹腔镜手术向单孔手术发展,目前已经在临床开展的主要单孔手术是经脐单孔腹腔镜手术。本文回顾和分析近年来的相关文献,对经脐单孔腹腔镜外科技术的发展和现状作一综述。     

经胃及阴道NOTES术后感染动物模型研究

Background  The infection risk of natural orifice transluminal endoscopic surgery (NOTES) is of concern. The aim of this study was to assess the safety of NOTES by investigating the intraperitoneal bacterial load during transgastric and transvaginal procedures with antiseptic or controling perioperative preparation.

Methods  Forty-five female pigs were randomly assigned to five equal groups: the transgastric (TG) control group (group A), the TG middle volume gastric lavage group (group B), the TG high volume lavage group (group C), the transvaginal (TV) control group (group D) and the TV study group (group E). The study groups received gastric or vaginal lavage and abdominal antimicrobial irrigation, while the control groups received neither. All animals were administered intravenous antibiotics, underwent NOTES peritoneoscopy and transumbilical laparoscopic cholecystectomy under NOTES view with sterile instruments. The viscerotomy was closed by laparoscopic suture. The animals were observed until necropsy was performed 14 days postoperatively. Quantitative bacteriologic cultures were taken from the gastric or vaginal aspirate before and after lavage; peritoneal fluid was collected before and after peritoneal irrigation and at necropsy.

Results  The surgical procedures were completed for all the pigs and all of them survived. The mean operative time of the TG group and the TV group was (81±27) minutes and (66±12) minutes, respectively. All animals survived for 14 days. At necropsy, significantly more peritoneal infections were noted in group A than in group D (5:9 vs. 0:9; P <0.05). No gross evidence of intra-peritoneal infection was found in groups B, C, D and E. Bacteriological evidence was seen in all pigs in group A, 7 pigs in group B, 6 pigs in group D, and none in groups C and E.

Conclusions  Without gastric or vaginal lavage and antibiotic peritoneal irrigation, the TG procedure has a higher infection rate than the TV access. After antiseptic preparation, the bacterial load significantly decreased in the TG group, which seems as safe as the sterile TV approach.

     

要正确认识NOTES

NOTES是natural orifice transluminal endoscopic surgery的英文缩写，顾名思义，就是内镜经自然腔道穿出空腔脏器壁，在空腔脏器外进行的外科手术。这里要注意“内镜”两字，目前学术界公认的“内镜”是指纤维软镜，“腔镜”是指硬镜，NOTES与NOES（natural orifice endoscopic surgery）即自然腔道内镜手术的含义截然不同。前者的内镜操作是在空腔脏器之外，后者是在空腔脏器内操作。